Provider Demographics
NPI:1649017815
Name:FONTAINE, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 FENTRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1214
Mailing Address - Country:US
Mailing Address - Phone:386-272-7440
Mailing Address - Fax:
Practice Address - Street 1:728 FENTRESS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1214
Practice Address - Country:US
Practice Address - Phone:386-272-7440
Practice Address - Fax:386-204-0948
Is Sole Proprietor?:No
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW18455101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health